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General NPI Number Information
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NPI Number | 1215287008
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Entity Type | Individual
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Provider Name | LIBERTY ZARIAH JACKSON OTR/L
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Gender | Female
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Dates
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Enumeration Date | 09/19/2012
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Last Update Date | 09/19/2012
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Provider Practice Location Address
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Address Line | 2901 FALK RD
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City | VANCOUVER
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State | WA
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Zip | 98661-6392
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Country | US
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Telephone | 360-313-1250
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Fax |
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Provider Business Mailing Address
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Address Line | 5718 SW SHATTUCK RD
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City | PORTLAND
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State | OR
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Zip | 97221-1038
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Country | US
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Telephone | 503-704-7967
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225XP0200X
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Taxonomy Name | Pediatric Occupational Therapist
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License Number | OT60234654
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License Number State | WA
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Taxonomy #2
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Taxonomy Code | 225XP0200X
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Taxonomy Name | Pediatric Occupational Therapist
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License Number | OT287043
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License Number State | OR
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